A patient with multiple rib fractures: Imaging modalities

and clinical significance

Alvin J. Garcia MS III

Core Radiology Clerkship

Agenda

Presentation of patient

Basic anatomy of ribs

Menu of radiological tests

When to image the ribs and their significance

Causes of rib fractures and associated complications

Our Patient

A 34 year old female pedestrian presents to the ED after being hit by moving vehicle on her left side at a speed of 30mph whilecrossing street, and landed on the hood of car.

She had no loss of consciousness.

She was brought to ED by ambulance.

Patient was hemodynamically stable with good ventilation. Vital signs were within normal limits and she was AOx3.

Physical exam was normal except for left sided chest wall pain and a left elbow laceration.

Her lab work was unremarkable.

Agenda

Presentation of patient

Basic anatomy of ribs

Menu of radiological tests

When to image the ribs and their significance

Causes of rib fractures

Rib Anatomy

Thorax consists of the12 ribs, sternum [with manubrium (M), sternum (S), xiphoid (X)] and clavicle (C). Scapula is located posteriorly.

First 7 ribs are connected with the vertebral column, posteriorly, and with the sternum,anteriorly, by means of the costal cartilages. So called, true ribs

Ribs 8-10 are attached to the cartilage of the rib above.

The 11th and 12th ribs are free anteriorly.

Image source: Rib Fractures. http://emedicine.medscape.com/article/395172-overview. August 20th, 2009.

A Transverse Diagram of the Thorax

Shown at level of 9th ribCVJ – costovertebral junctionVB –vertebral bodyCCJ –costochondral junctionS- sternum

Image source: Rib Fractures. http://emedicine.medscape.com/article/395172-overview. August 20th, 2009.

Anatomic Correlation

Fracture of the first to third ribsextremely rare and more commonly associated with either multiple rib fractures or life-threatening injuries. Fractures of the first rib imply a violent forceThese patterns of fractures may signify injury to the adjacent subclavian vein and brachial plexusFirst rib often fractured posteriorly

Fracture of the fourth to tenth ribs 4-10 ribs are most often broken. Multiple fractures can present as flail chestInward displacement of the fracture fragments at the time of the injury may lacerate the lung parenchyma, heart and vessels and other internal thoracic structures.

Fractures of eleventh to twelfthRisk of hemorrhage around and within the visceral organsFractures of the lower ribs are also commonly associated with liver, spleen, kidneys, and diaphragm

Source: Doty CI and Sinert RH. http://emedicine.medscape.com/article/825981-overview

Agenda

Presentation of patient

Basic anatomy of ribs

Menu of radiological tests

When to image the ribs and their significance

Causes of rib fractures

Menu of Radiological Tests:

Chest X-rayComputed tomographyUltrasoundMRIBone ScanSingle Photon Emission CT (SPECT)

Menu of radiological tests: Chest X-ray

Initial study of choice.CXR may miss up to 50% of rib fractures, but is still useful.Not sensitive for costal cartilage or stress fracture.Also, important for diagnosing processes associated with rib fractures such as:

pnuemothoraxhemothoraxpulmonary contusionpneumomediastinumpneumoperitoneumaortic injury.

Source: Bhavnagri SJ and Mohammed TLH.

There is a subtle step-off pattern.

Patient was imaged with trauma board.

Trauma board

PACS, BIDMC

Our patient: AP Chest X-ray showing fractures of the 4th and 5th Ribs.

Menu of radiological tests: Ultrasound

Advantagesmore sensitive than chest radiograph (78% vs. 12%). Detects costal cartilage fractures and costochondral junction fractures better than radiography.view of multiple planes and visualize in real time.You can scan entire rib at site of maximal tenderness and then adjacent ribs. Once rib fracture diagnosed, one can quickly rule out pneumothorax and hemothorax as well.

DrawbacksNot widely used.Time consuming and more costly than plain radiograph.Skill dependentCan't assess first rib under clavicle and upper ribs under scapula.Role limited to situations in which the diagnosis of a rib fracture alone is important

Chan, JJ et al. Emergency bedside ultrasound for the diagnosis of rib fractures. American Journal of Emergency Medicine (2009) 27, 617–620

http://www.ncbi.nlm.nih.gov.ezp-prod1.hul.harvard.edu/sites/entrez

Long-axis view of a fractured left third rib of a patient using a 12-MHz linear transducer. The disruption of the hyperechoic cortical alignment is shown by the arrows

Companion patient #1: Rib Ultrasound

Chan, JJ et al. Emergency bedside ultrasound for the diagnosis of rib fractures. American Journal of Emergency Medicine (2009) 27, 617–620http://www.ncbi.nlm.nih.gov.ezp-prod1.hul.harvard.edu/sites/entrez

Menu of radiological tests: Computed Tomography

AdvantagesBest modality to visualize ribsMay help detect fracture lines, fracture fragments, callus formation, pleural hematoma, or pnuemothorax.Can be used to evaluate costal cartilage injury.Specific bone reconstruction algorithms and 3D reconstructions improve detection by CT.

DisadvantageCostly, time consuming, not always available, radiation exposure

Source: Bhavnagri SJ and Mohammed TLH.

Menu of radiological tests: RN Bone Scan, SPECT, MRI

sensitive but not specificTechnetium (Tc 99m) methylene diphosphonate bone scanning

Radionuclide Bone scan

SPECT

MRI

• can help localize abnormal hot spot on bone• can represent number of conditions beside rib fracture. • very sensitive for stress fractures.

• No role yet in rib fracture evaluation

Source: Bhavnagri SJ and Mohammed TLH.

Agenda

Presentation of patient

Basic anatomy of ribs

Menu of radiological tests

When to image the ribs and their significance

Causes of rib fractures

Recommended clinical management of patients with a history of chest trauma.

When to image the ribs and their significance

Bhavnagri, SJ and Mohammed, TLH. When and how to image a suspected broken rib. Cleveland journal of medicine. (2009) 76(5):309

When to image the ribs and their significance

In patients with minor blunt trauma, with little suspicion of associated injury or complication, plain radiography is likely sufficient.

CT is imaging study of choice in patients with penetrating or major chest or abdominal trauma.

Rib fractures correlate significantly to mortality and morbidity. In elderly, multiple rib fractures are associated with increased number of ventilator days, intensive care unit days, and length of stay (Bulger et. al)-Pneumonia occurred in 31% of elderly vs. 17% of young and mortality was 22% in elderly vs. 10% in young.

Mortality increased as number of rib fractures increased. (Sharma et. al)-Patients with 1 or 2 rib fractures had a 3% mortality rate, and patients with 6 or more fractures had a 32% mortality

Fractures can cause flail chest (when two or more ribs are fractured in two or more places) and can lead to ventilatory insufficiency due to ineffective respiratory action. (Doty and Sinert)-This condition requires aggressive pain control, pulmonary toilet, and mechanical ventilation

Why confirm a rib fracture?

1. Detect associated injury-pneumothorax, hemothorax pulmonary contusion, flail chest, pneumonia, vascular and nerve damage, abdominal organ injury

2. Prevent complications such as atelectasis and acute respiratory failure

3. Document the injury-medical-legal issues especially in cases of assault, motor vehicle crash, occupational injury or abuse

4. Find appropriate pain management -undiagnosed patients can have long standing refractory pain.-NSAIDs are usually given for soft tissue injury but rib fracture may need narcotics or nerve block.

5. Detect pathologic fractures

6. Count how many ribs are broken

Management of rib fractures

Uncomplicated rib fractures do not require radiographic diagnosis because it has little impact on patient management.

Treatment is aimed at pain management

Operative management of rib fractures still topic of debate and not used widely.

Indications: flail chest, chest wall deformity, pain and disability, non-union

Agenda

Presentation of patient

Basic anatomy of ribs

Menu of radiological tests

When to image the ribs and their significance

Causes of rib fractures

Causes of rib fractures

Rib fractures most commonly identified injuries of the chest.10% of all traumatic injuries and 14% of all chest-wall injuries

Trauma-the most common cause of rib fractures, includes penetrating injuries and blunt injury to the chest wall. MVA, assault, sports, cardiopulmonary resuscitation, physical abuse, and rarely, paroxysms of coughing.

Cancer-causes pathologic fractures. Primary tumors or metastases.

Stress fractures -high level athletes whose activity involves repetitive musculoskeletal loading. Activities include rowing, pitching, throwing, basketball, weight-lifting, ballet, golf, gymnastics, and swimming.

Metabolic-hyperparathyroidism, glucocortical steroid administration, Paget’s disease, gout

Inflammatory-ankylosing spondylitis

Infection

Bhavnagri, SJ and Mohammed, TLH. When and how to image a suspected broken rib. Cleveland journal of medicine. (2009) 76(5):309

Agenda

Presentation of patient

Basic anatomy of ribs

Menu of radiological tests

When to image the ribs and their significance

Causes of rib fractures and associated complications

Back to our Patient: 35 year old female is brought to the ED after being hit by motor vehicle.

A chest x-ray was performed which showed left sided rib fractures (3-6)

CT scans of the head, c-spine, abdomen showed no traumatic process.

PACS, BIDMC

Fracture of the 6th rib on CT axial view

Our patient had a CT which showed multiple rib fractures.

4th and 5th rib fractures on CT axial view

PACS, BIDMC

A CT axial image taken superiorly shows a pneumothorax with pulmonary contusion

PACS, BIDMC

CT image of 5th rib fracture on sagittal view

PACS, BIDMC

5th rib fracture seen as hyperdense line

CT coronal view of chest showing fractures of rib 3rd

and 5th rib

PACS, BIDMC

3rd and 5th rib fractures. Patient also has fractures of 4th and 6th rib which are not visible on this plane

Rib fracture with callus formation in 76-year-old man. CT image shows well-defined fracture (arrow) and periosteal callus formation (c).

Source: Michel De Maeseneer, Johan De Mey, Leon Lenchik, Hendrik Everaert and Michel Osteaux. Helical CT of Rib Lesions: A Pattern-Based Approach, American Journal of Roentgenology (2004) 182 (1): 173.

Case continued…

Patient was admitted to the medicine floor with chest pulmonary toilet and pain control.

Days later, she transferred to the intensive care unit with worsening respirations, partly due to pain control for her rib fractures and her worsening contusions. She was intubatedelectively in the intensive care unit.

She later developed a pneumonia, which was treated with levofloxacin. She remained on the ventilator for one week and was later extubatedand transported to the medicine floor.

She was discharged in a good condition

Here are two more examples…

Companion patient # 2. CT of a 40 M after 18ft fall with multiple rib fractures on coronal view.

PACS, BIDMC

He suffered a hemopneumothorax, grade III splenic laceration and an adrenal hematoma (not visible on image)

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Rib fractures of left thorax

Companion patient #3. CT of a 60M post MVC with flail chest (rib fractures 6-12), pulmonary contusion, grade V shattered spleen, and shock bowel.

PACS, BIDMCRib fracture, pulmonary contusion and shattered spleen

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Take Home Points

Rib fractures are common pathologies.Most are managed conservativelyConfirmation is important, however, because rib fractures can have associated complications

References

1. Bhavnagri SJ and Mohommed MD. When and how to image a suspected broken rib. Cleveland Journal of Medicine. 2009. 76(5):309-314. http://www.ncbi.nlm.nih.gov.ezp- prod1.hul.harvard.edu/sites/entrez

2. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. Journal of Trauma: Injury, Infection and Critical Care. 2000. 48(6):1040-1046.

3. Chan SS. Emergency bedside ultrasound for the diagnosis of rib fractures. American Journal of Emergency Medicine. 2009. 27:617-620.

4. De Maeseneer, M, De May J, Lenchik L, Everaert H, Osteaux M. Helical CT of rib lesions. American Journal of Roenterology. 2004. 182: 173-179.

5. Doty CI and Sinert RH. Rib fractures http://emedicine.medscape.com/article/825981-overview6. Richardson JD, Franklin GA, Heffley S, Seligson D. Operative fixation of chest wall

fractures:An underused procedure? The American Surgeon. 2007. 73:591-5967. Sharma OP, Oswanski MF, Jolly S, Lauer SK, Dressel R Stombaugh HA. The perils of rib

fractures.The American Surgeon. 2008. 74:310-314.

Acknowledgements

Karen LeeJim WuGillian LiebermanMaria Levantakis